Clinical Reviewer

Clinical Reviewer

Location: Hybrid / Remote
Employment Type: Full‑Time

Position Summary

The Clinical Reviewer is responsible for assessing, planning, and evaluating medical treatment and return‑to‑work readiness through detailed review and analysis of medical and claim documentation. This role partners closely with claims professionals to support effective medical and disability management while ensuring high‑quality, timely, and cost‑effective claim outcomes.

Key Responsibilities

• Review, analyze, and document medical and claim information to develop clinical recommendations and action plans.
• Provide clear clinical rationale and guidance to support claim handlers in managing medical and disability components of claims.
• Assess medical complexity and determine appropriate treatment guidelines based on injury, comorbidities, and other contributing factors.
• Establish projected disability durations and recovery expectations.
• Manage clinical referrals and support services, including causation analysis and cost projections.
• Collaborate with claims staff to promote optimal medical outcomes and timely return to work.

Qualifications

Required:

• Active Registered Nurse (RN) license or comparable healthcare designation.
• Minimum of three (3) years of clinical experience in one or more of the following areas:
  • Orthopedics
  • Neurology
  • Rehabilitation
  • Medical/Surgical
  • Occupational Health

Preferred:

• Bachelor’s degree in a health‑related field or equivalent relevant experience.
• Prior critical care experience (e.g., Emergency Room or Intensive Care Unit).
• Professional certifications such as CCM (Certified Case Manager) or CLCP (Certified Life Care Planner).

Core Competencies

• Customer‑focused approach with strong service orientation
• Excellent analytical, critical thinking, and problem‑solving skills
• Strong written and verbal communication abilities
• Proficiency in Microsoft Office applications
• Adaptability, innovation, and commitment to continuous improvement
• Ability to build strong working relationships across teams

Work Arrangement

This position offers a Hybrid or Remote work schedule:

• Candidates located near an office location are expected to work in the office three days per week (Tuesday–Thursday).
• Candidates outside of an office location may work remotely, with occasional in‑office presence as business needs require.